Provider Demographics
NPI:1295210631
Name:WANG, MIKE (LMT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3231
Mailing Address - Country:US
Mailing Address - Phone:419-231-3665
Mailing Address - Fax:
Practice Address - Street 1:4030 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2146
Practice Address - Country:US
Practice Address - Phone:419-231-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.019051225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist